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when doc dictates L-thyroid sm

Posted By: tiff on 2008-02-21
In Reply to:

Subject: when doc dictates L-thyroid sm

Does he mean levothyroxine or Levothroid?


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Under PMH. MD dictates: sm
Subject: Under PMH. MD dictates: sm

 Status post trauma/repair to patient’s eye.


 


Would you leave this as is with the slash or change it?  I am permitted to change things when necessary.  Thanks.


What do you do when the doc dictates sm
Subject: What do you do when the doc dictates sm

... and I gave the patient 50 "mikes" of whatever medication.  One said to spell it m-i-q-u-e-s, one said to use m-i-k-e-s, and one hospital said not to use it at all. So, does it stand for micrograms?  Should we use slang?  Aghh!  Help, please.
I would put as doc dictates..sm
Subject: I would put as doc dictates..sm

if he says "calcium one every day" I would not input the q.d., but I would expand it as "calcium, one tablet every day." jmo and how I have been doing it with no complaints.
Exactly the way MD dictates it
Subject: Exactly the way MD dictates it

If the patient could see anything at all (I had one today where the patient could see 20/1760), then the MD would have given the value, but when there is nothing there, you just type nothing. I have a verbatim account, but even if I didn't, I still would not change it to 20/0 as that lone "0" could be mistaken as something else.
If a Dr. dictates
Subject: If a Dr. dictates

"posterior tib", meaning posterior tibial artery, do you type the abbreviation or go ahead and type out tibial?
if that's the way he/she dictates it...then yes I would. nm
Subject: if that's the way he/she dictates it...then yes I would. nm

xxx
The doctor dictates
Subject: The doctor dictates

His aortic valve appeared well-(s/l seated).  I found some examples like that, but am unsure of certainty and spelling accuracy?  Thank you in advance for any help.
Think that one is bad? my md dictates things like this...sm
Subject: Think that one is bad? my md dictates things like this...sm

I used a small, tiny, little Q-tip .... and he doesn't want me to change it.   Bizarre!!!
I have a doc that dictates same thing
Subject: I have a doc that dictates same thing

mine means adenosine thallium
I leave it as whatever the doc dictates.
Subject: I leave it as whatever the doc dictates.

It's not my job to keep them politically correct.
Do I change it when he dictates cc? nm
Subject: Do I change it when he dictates cc? nm

!
I have a psychiatrist who dictates like that. sm
Subject: I have a psychiatrist who dictates like that. sm

I leave most of his stuff as is even though the account is not verbatim.  A lot of times I end up wondering WTH he is talking about.  When I first got his dictations I was going back to read and relisten because I thought I must have scrambled something.  Give them what they dictate, if they don't like what they read maybe they'll take the time to think before they dictate next time. 
Dictates died s/l **min** CVA
Subject: Dictates died s/l **min** CVA

Dictates died from m-i-n CVA. I can't verify min CVA anywhere. Any suggestions?
dictates **phagiagram**
Subject: dictates **phagiagram**

He clearly dictates *phagiagram* or something that is VERY similar to that. I don't hear a *dys*. I tried google and am getting zero hits.

Do you think I should I QA it or would it be fine to just use *phagiagram*?

Thanks in advance.
You transcribe what he/she dictates.
Subject: You transcribe what he/she dictates.

You transcribe the values as dictated. If he says "Cholesterol profile" and then just lists the values, then I would put a colon after profile and just list them.
thyroid ?
Subject: thyroid ?

Could he be saying "enlargement" or "nodules".  I would thing "enlargement" would be the most logical of the two.
does this have to do with thyroid?
Subject: does this have to do with thyroid?


Yes it is the thyroid. Thank you so much! -nm-
Subject: Yes it is the thyroid. Thank you so much! -nm-

x
I have an ESL who dictates a lipid profile
Subject: I have an ESL who dictates a lipid profile

and then says "lipid profile comment NIHN." What in the world does that mean?
whatever doc dictates. Would not use beats/minute tho. nm
Subject: whatever doc dictates. Would not use beats/minute tho. nm


Yes. I transcribe for a cardiologist who always dictates
Subject: Yes. I transcribe for a cardiologist who always dictates


Could be, although he only dictates 1 syllable. I think I will flag. Thanks.
Subject: Could be, although he only dictates 1 syllable. I think I will flag. Thanks.


provider dictates bivicd sm
Subject: provider dictates bivicd sm

Would you put bi-V ICD, biV-ICD, bi-V-ICD or something else? Says it multiple times in note. Thanks!
dictates ureteral meatus
Subject: dictates ureteral meatus

Could that be right?  Or do you think dictator means urethral?  Talking about vesicoureteral reflux in a male. 


 


Thanks!!!


Is it Mersa or MRSA? he dictates
Subject: Is it Mersa or MRSA? he dictates


Doc dictates 3/5 systolic murmur (sm)
Subject: Doc dictates 3/5 systolic murmur (sm)

I always thought the last number was 6.  Does this make sense?  TIA!
The patient has MS, dictates she cannot s/l antigravitate the leg.
Subject: The patient has MS, dictates she cannot s/l antigravitate the leg.

Have not heard the term antigraviate before, and cannot find it anywhere. That is all the context I have
grr. doc dictates s/l alipta, spells a-l-m-i-t-a. sm
Subject: grr. doc dictates s/l alipta, spells a-l-m-i-t-a. sm

It's a second choice chemotherapy agent after carboplatin/Taxotere rejected by patient.  Any thoughts? 


Many thanks in advance!


dictates what sounds like omPUREizole
Subject: dictates what sounds like omPUREizole

I'm not finding this anywhere. Anyone have a clue?
Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!
Subject: Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!


dictates glucocheck/glucochecked
Subject: dictates glucocheck/glucochecked

Is that right? I can't 100% verify.

Thank you.
Your choice unless client dictates different.
Subject: Your choice unless client dictates different.


T3, T4 and TSH are thyroid studies. sm
Don't know about the cytes part you are hearing.
SICU thyroid?
Subject: SICU thyroid?

SICU thyroid?
thyroid mass
Subject: thyroid mass

Under medical history the doctor says, pretty clearly, "stick left thyroid mass"


 


I cannot verify this term. Any help appreciated. thank you


Possibly Thyroid
Subject: Possibly Thyroid

It's 20 mg. The patient also has orthostatic edema, acute on chronic renal insufficiency and hypokalemia.
I have this at last once a week and it is always thyroid. I have never
Subject: I have this at last once a week and it is always thyroid. I have never

had it with a cardiac origin. 
Cytomel - thyroid- nm
Subject: Cytomel - thyroid- nm

ss
? thyroid panel. (n/m)
Subject: ? thyroid panel. (n/m)


thyroid nodule
Subject: thyroid nodule

thyroid lumpectomy is scheduled
thyroid retractor sm
Subject: thyroid retractor sm

Doc is saying Mahoney thyroid retractor. I cannot locate this after searching through numerous books.  I do find Mahorner thyroid retractor.  Anyone heard of  Mahoney?  TIA.
thyroid question
Subject: thyroid question


  1. Hypothyroidism-clinically s/l youth thyroid.  Could this be.....cannot find it in my books!!!! 

Can someone help with thyroid medication.
Subject: Can someone help with thyroid medication.

Dictates patient is hyperthyroid and is on s/l levothyroid 0.125/day.
Yes, it is thyroid surgery, Thanks!
Subject: Yes, it is thyroid surgery, Thanks!


thyroid question
Subject: thyroid question

There is a past history of hyperthyroidism but TSH on 03/11/2008 was 0.86, indicating a ?? thyroid state.  S/l "new" thyroid state.  Thanks for the help!


Thyroid ultrasound help!
Subject: Thyroid ultrasound help!

 


A second s/l interbrachiable/interpranchable nodule measuring 1.5 cm * 0.9 * 1.4 cm is present overlying the lower pole of the right lobe.


Doc also talks about interpranchable  mass measuring 3.1 cm * 3.5 * 2.2 is seen overlying the midbody of the right lobe.


This is an ultrasound of thyroid gland..Any help??


thyroid lobectomy
Subject: thyroid lobectomy

they can remove just 1 lobe to relieve a goiter
thyroid enlargement? nm
Subject: thyroid enlargement? nm


could it be "Levoxyl" (thyroid) ??
Subject: could it be "Levoxyl" (thyroid) ??


Okay, I'm not explaining right. Doc actually dictates "Positive Hepatitis CAB". nm
Subject: Okay, I'm not explaining right. Doc actually dictates "Positive Hepatitis CAB". nm


In Vital SIgns, doc dictates "MAP 77". ?? sm
Subject: In Vital SIgns, doc dictates "MAP 77". ?? sm

VITAL SIGNS:  Temperature 36.0, pulse rate 62, respiratory rate 16, systolic 112, diastolic 160, MAP 77.